Cardiac Rehabilitation November 1st, 2007 Jeffrey Marogil, MD UIC Cardiology

Introduction Up until the 1950s, strict bed rest was thought to be the best medicine after a heart attack. Following discharge moderately stressful activity such as climbing stairs was discouraged for a year or more.

Introduction "The patient is to be guarded by day and night nursing and helped in every way to avoid voluntary movement or effort." Thomas Lewis, 1933

Introduction Despite the known benefits of cardiac rehabilitation (CR) and widespread endorsement (CR) is vastly underutilized and less than 30% of patients participate in CR programs after a CV event.

Overview What is cardiac rehab Medicare Coverage Evidence Components, Terminology & Contraindication Safety Medicare Coverage Evidence STEMI UA/NSTEMI Stable angina & Percutaneous coronary intervention Coronary bypass surgery Heart failure Rehab Options at UIC and in IL Conclusions

What is Cardiac Rehab?

Definition: Cardiac rehabilitations services are comprehensive, long-term programs involving medical evaluation, prescribed exercise, cardiac risk factor modification, educations and counseling. These programs are designed to limit the physiologic and psychological effects of cardiac illness, reduce the risk for sudden death or reinfacrction, control cardiac symptoms, stabilize or reverse the atherosclerotic process, and enhance the psychosocial and vocational status of selected patients

2007 American Association of Cardiovascular and Pulmonary Rehabilitation/AHA/ACC Guidelines Performance Measures on Cardiac Rehabilitation for Referral to and Delivery of Cardiac Rehabilitation/Secondary Prevention Services:  J Am Coll Cardiol 2007;50:1400-33

Cardiac Rehab Terminology Phase 1: Inpatient Rehab - A program that delivers preventive and rehabilitative services to hospitalized patients following an index CVD event Phase II: Early outpatient CR - a programmed that delivers preventive and rehabilitative services to patients in the outpatient setting early after CVD event within the first 3-6 months and continuing for up to 1 year Phase III: Long-term outpatient CR - Longer term delivery or preventive and rehab

Cardiac Rehab Terminology Risk Stratification for Exercise Class A Class B Class C Class D Guidelines published by the American Heart Association use four categories of risk according to clinical characteristics

Cardiac Rehab Terminology Class A: apparently healthy and no clinical evidence of increased cardiovascular risk of exercise. Class B: established CHD that is clinically stable. Overall low risk of cardiovascular complications of vigorous exercise. Guidelines published by the American Heart Association use four categories of risk according to clinical characteristics

Cardiac Rehab Terminology Class C: moderate or high risk of cardiac complications (multiple myocardial infarctions or cardiac arrest, NYHA class III or IV, Exercise capacity of < 6 METs, or significant ischemia on the exercise test. Class D: unstable disease for whom exercise is contraindicated. Guidelines published by the American Heart Association use four categories of risk according to clinical characteristics

Absolute Contraindication to Exercise Absolute Acute myocardial infarction (within two days) Unstable angina Uncontrolled cardiac arrhythmias causing symptoms or homodynamic compromise Symptomatic severe aortic stenosis Uncontrolled symptomatic heart failure Acute pulmonary embolus or pulmonary infarction Acute myocarditis or pericarditis Active endocarditis Acute aortic dissection Acute noncardiac disorder that may affect exercise performance or be aggravated by exercise Inability to obtain consent Exercise standards for testing and training: a statement for healthcare professionals from the American Heart Association. Circulation 2001; 104:1694

Relative Contraindication to Exercise Left main coronary stenosis or its equivalent Moderate stenotic valvular heart disease Electrolyte abnormalities Severe hypertension (systolic 200 mmHg and/or diastolic 110 mmHg) Tachyarrhythmias or bradyarrhythmias, including atrial fibrillation with uncontrolled ventricular rate Hypertrophic cardiomyopathy and other forms of outflow tract obstruction Mental or physical impairment leading to inability to cooperate High-degree atrioventricular block Exercise standards for testing and training: a statement for healthcare professionals from the American Heart Association. Circulation 2001; 104:1694;

Cardiac Rehab Terminology Content and duration : Each exercise session includes three phases: Warm-up for 5 to 10 minutes. Warm-up exercises consist of stretching, flexibility movements Conditioning or training phase, which consists of at least 20 minutes and preferably 30 to 45 minutes of continuous aerobic activity. Cool-down for 5 to 10 minutes. permits a gradual recovery from the conditioning phase.

Cardiac Rehab Omission of cool-down can result in a transient decrease in venous return, reducing coronary blood flow when heart rate and myocardial oxygen consumption remain high. Adverse consequences can include hypotension, angina, ischemic ST-T changes, and ventricular arrhythmias.

Maximum Heart Rate Estimated as 220 minus the age in years (most common) Maximum heart reached at peak exercise during a symptom-limited exercise tolerance test

Cardiac Rehab Exercise Intensity Exercise intensity has been categorized using the percent HRmax as: Light (<60 percent) Moderate (60 to 79 percent) Heavy (80 percent) The incremental benefit of very high intensity exercise (>90 percent of HRmax) is small and is not recommended

Cardiac Rehab Patients with stable angina may have an exercise prescription based upon 60 to 70 percent of the heart rate at which ischemic ST segment changes or anginal symptoms appear.

Cardiac Rehab Terminology One MET is defined as 3.5 mL O2 uptake/kg per min, which is the resting oxygen uptake in a sitting position.

Extra Marital sex

Overview What is cardiac rehab Medicare Coverage Evidence Components, Terminology & Contraindication Safety Medicare Coverage Evidence STEMI UA/NSTEMI Stable angina Percutaneous coronary intervention Coronary bypass surgery Heart failure is not covered Rehab Options at UIC and IL Conclusions

Cardiac Rehab Safety Supervision: Important consideration when prescribing an exercise Patients at moderate or high risk (Class C) should participate in a medically supervised program with ECG monitoring and personnel and equipment suitable for advanced cardiac life support. This level of supervision should be continued for 8 to 12 weeks until the safety of the prescribed exercise regimen has been established

Cardiac Rehab Safety Exercise in Class B and C patients is associated with a small risk of adverse events. The 2007 American Heart Association scientific statement on exercise the acute cardiovascular event rate estimated at one event in 60,000 to 80,000 hours of supervised exercise (cardiac arrest, death or MI).

Cardiac Rehab Safety Mortality rate in these setting is 1 per 784,000 patient-hours. Non fatal MI rate was 1 per 294,000 patients-hours

Overview What is cardiac rehab Medicare Coverage Evidence Components, Terminology & Contraindication Safety Medicare Coverage Evidence STEMI UA/NSTEMI Stable angina Percutaneous coronary intervention Coronary bypass surgery Heart failure is not covered Rehab Options at UIC and IL Conclusions

Medicare Coverage March 2006 Medicare expanded coverage of CR to include Heart valve repair/replacement Percutaneous transluminal coronary angioplasty or stenting Heart or heart lung transplant Also extended the time frame of performing the services to 36 sessions (generally 2-3 sessions per week for 12-18 weeks)

Medicare Coverage COVERED Documented diagnosis of acute myocardial infarction within the preceding 12 months Coronary bypass surgery Stable angina Heart valve repair/replacement Percutaneous coronary intervention Heart or heart-lung transplant NOT COVERED Heart failure

Overview What is cardiac rehab Medicare Coverage Evidence Components, Terminology & Contraindication Safety Medicare Coverage Evidence STEMI UA/NSTEMI Stable angina Percutaneous coronary intervention Coronary bypass surgery Heart failure is not covered Rehab Options at UIC and IL Conclusions

Evidence STEMI: Class IC Cardiac rehabilitation/secondary prevention programs, when available, are recommended for patients with STEMI, particularly those with multiple modifiable risk factors and/or those moderate- to high-risk patients in whom supervised exercise training is warranted New ACC/AHA Guidelines for the Management of Patients with STEMI 11/2/2004

Evidence post STEMI Meta-analysis (8440 patients) of total mortality for the exercise-only intervention demonstrated a reduction in all-cause mortality (random effects model OR 0.73 [0.54, 0.98]) compared with usual care. Comprehensive cardiac rehabilitation reduced all-cause mortality but to a lesser degree (OR 0.87 [0.71, 1.05]). Neither of the interventions had any effect on the occurrence of nonfatal MI. Jolliffe JA, Rees K, Taylor RS, Thompson D, Oldridge N, Ebrahim S. Exercise-based rehabilitation for coronary heart disease. Cochrane Database Syst Rev 2001 CD001800.

Evidence post STEMI Results were of limited reliability because the quality of reporting in the studies was generally poor, and there were high losses to follow-up Individual trials were small. Trials were performed in the 1980s and earlier, before the contemporary advances in both the therapy and secondary prevention of MI

Updated 2007 UA/NSTEMI Guidelines NSTEMI: CLASS IB Cardiac rehabilitation/secondary prevention programs, when available, are recommended for patients with UA/NSTEMI, particularly those with multiple modifiable risk factors and those moderate- to high-risk patients in whom supervised or monitored exercise training is warranted. ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non–ST-Elevation Myocardial Infarction

Updated 2007 UA/NSTEMI Guidelines 2005 meta-analysis of 11 trials of 2285 patients with coronary disease (most but not all post-MI) who were randomly assigned to exercise rehabilitation alone or control therapy. Exercise was associated with a significant reduction in all-cause mortality (6.2 versus 9.0 percent, summary risk ratio 0.72, 95% CI 0.54-0.95). There was an almost significant reduction in recurrent MI in the exercise group (summary risk ratio 0.76, 95% CI 0.57-1.01). Meta-analysis: secondary prevention programs for patients with coronary artery disease. AU Clark AM; Hartling L; Vandermeer B; McAlister FA SO Ann Intern Med 2005 Nov 1;143(9):659-72.

Updated 2007 UA/NSTEMI Guidelines Retrospective study among 1,821 persons from 1982 and 1998, with an incident MI hospitalized in Olmsted County 58% men, 46% age >70 years) 55% participated in cardiac rehabilitation. Participants had a lower risk of death and recurrent MI at three years (p < 0.001 and p = 0.049, respectively). The survival benefit associated with participation was stronger in more recent years RR for 1998 vs. 1982 0.28, 95% CI 0.18 to 0.43; RR for 1990 vs. 1982 0.41, 95% CI 0.33 to 0.52). Witt BJ, Jacobsen SJ, Weston SA, et al. Cardiac rehabilitation after myocardial infarction in the community. J Am Coll Cardiol 2004; 44:988 –96.

Figure 2 Expected and observed survival by participation in cardiac rehabilitation. (A) non-participants; (B) participants.

Overview What is cardiac rehab Medicare Coverage Evidence Components, Terminology & Contraindication Safety Medicare Coverage Evidence STEMI UA/NSTEMI Stable angina & Percutaneous coronary intervention Coronary bypass surgery Heart failure is not covered Rehab Options at UIC and IL Conclusions

Stable Angina Class IB: Comprehensive cardiac rehabilitation program ACC/AHA 2002 Guideline Update for the Management of Patients With Chronic Stable Angina

Sable Angina Nine randomized trials and four randomized trials have examined objective measures of ischemia One study used ST-segment depression on ambulatory monitoring, Three used exercise myocardial perfusion imaging . Three of the four studies demonstrated a reduction in objective measures of ischemia in those patients randomized to the exercise group compared with the control group.

Stable Angina

Following PCI Cardiac rehabilitation programs are recommended, particularly for those patients with multiple modifiable risk factors and/or those moderate- to high-risk patients in whom supervised exercise training is warranted. ACC/AHA/SCAI 2005 Guideline Update for Percutaneous Coronary Intervention

Overview What is cardiac rehab Medicare Coverage Evidence Components, Terminology & Contraindication Safety Medicare Coverage Evidence STEMI UA/NSTEMI Stable angina & Percutaneous coronary intervention Coronary bypass surgery Heart failure is not covered Rehab Options at UIC and IL Conclusions

Rehab & CABG Class IB Cardiac rehabilitation should be offered to all eligible patients after CABG. ACC/AHA Coronary Artery Bypass Graft Surgery (CABG): Guideline Update for Date: 2004

Rehab & CABG Cardiac rehabilitation has been shown to reduce mortality Cardiac rehabilitation beginning 4 to 8 weeks after coronary bypass and consisting of 3-times-weekly educational and exercise sessions for 3 months is associated with a 35% increase in exercise tolerance (P equals 0.0001), a slight (2%) but significant (P equals 0.05) increase in HDL-C, and a 6% reduction in body fat (P equals 0.002) Milani RV, Lavie CJ. The effects of body composition changes to observed improvements in cardiopulmonary parameters after exercise training with cardiac rehabilitation. Chest 1998; 113:599-601

Overview What is cardiac rehab Medicare Coverage Evidence Components, Terminology & Contraindication Safety Medicare Coverage Evidence STEMI UA/NSTEMI Stable angina & Percutaneous coronary intervention Coronary bypass surgery Heart failure is not covered Rehab Options at UIC and IL Conclusions

Rehab & CHF In the 1970s, exercise training of HF patients was discouraged due to concerns of worsening symptoms. Early observations in the 1980s documented improvements in exercise function for patients with HF with a low rate of complications.

Rehab & CHF ACC/AHA guideline summary: Management of patients with current or prior symptoms of heart failure (HF) and a reduced left ventricular ejection fraction (LVEF) Class IC- Exercise training as an adjunctive approach to improve clinical status in ambulatory patients.  

Rehab & CHF Meta-analysis of nine randomized controlled trials including 801 patients (395 of whom received exercise training compared to 406 controls) Exercise training reduces hospitalization and improves survival in patients with heart failure. Follow up of 705 (729) days there were 88 (22%) deaths in the exercise arm and 105 (26%) in the control arm. (hazard ratio 0.65, 95% confidence interval, 0.46 to 0.92; log rank chi(2) = 5.9; P = 0.015). The secondary end point of death or admission to hospital was also reduced (0.72, 0.56 to 0.93; log rank chi(2) = 6.4; P = 0.011). BMJ 2004 Jan 24;328(7433):189. Epub 2004 Jan 16.

Rehab & CHF The HF ACTION trial is testing the hypothesis that exercise training will reduce the combined end point of hospitalization and mortality in patients with NYHA class II-IV heart failure This trial has completed enrollment and is positioned to completion in February of 2008. Approximately 1500 patients will participate around the country and Canada for an average of four years.

Overview What is cardiac rehab Medicare Coverage Evidence Components, Terminology & Contraindication Safety Medicare Coverage Evidence STEMI UA/NSTEMI Stable angina & Percutaneous coronary intervention Coronary bypass surgery Heart failure is not covered Rehab Options at UIC and IL Conclusions

Type of Rehab Programs Exercise only Cardiac Rehab programs Comprehensive Cardiac Rehab programs

UIC has an exercise only cardiac rehab program Outpatient PT Perform 3 lead EKG monitoring Develop training programs Willing to work with primary physicians Document results in power chart

AACVPR Founded in 1985, the American Association of Cardiovascular and Pulmonary Rehabilitation Certify comprehensive rehab programs 42 Certified programs in IL Advocate Christ Medical Center

Overview What is cardiac rehab Medicare Coverage Evidence Components, Terminology & Contraindication Safety Medicare Coverage Evidence STEMI UA/NSTEMI Stable angina & Percutaneous coronary intervention Coronary bypass surgery Heart failure is not covered Rehab Options at UIC and IL Conclusions

Conclusion: Cardiac Rehab Vastly underutilized with less than 30% of patients participating in CR programs after a CV event. Reasonable evidence of efficacy in various patient populations Covered by Medicare in many populations UIC does over exercise only programs Overall this is something I will utilize more of